Use of a Modified Liverpool Care Pathway in a Tertiary Asian Hospital: Is There Still a Role for It?

Introduction

The United Kingdom Liverpool Care Pathway (LCP) was developed in the United Kingdom in the 1990s by the Royal Liverpool University Hospital and Liverpool's Marie Curie Hospice to replicate the standard of care for dying patients in hospices across different care settings. It was a model of care that enabled health care professionals to focus on care of the dying patient and was meant to tailor care to the individual, taking into consideration physical, social, spiritual, and psychological needs. ¹

Prior to the Neuberger review, the LCP had been recognized and recommended as a model of good practice to support end-of-life care by various organizations including the National End of Life Care Strategy, General Medical Council, and the National Institute for Health and Care Excellence (NICE) Quality Standard.^2,3 In view of recent increasing public concerns with LCP use, an independent review of the LCP was undertaken. The results published in July 2013 showed major issues in areas of communication, documentation, initiation of the pathway, and clinical interpretation of the pathway. ⁴ The Neuberger review found that while the LCP worked well when operated by well-trained, well-resourced, and sensitive clinical teams, other health care workers were treating the LCP as a set of instructions and prescriptions rather than a guideline for initiatives in end-of-life care. In some cases it was initiated by junior staff during out-of-office hours without supervision. The reviewers also elicited feedback from caregivers of patients who had been put on the LCP, where some caregivers felt that the pathway was a definite pathway to death, with patients being deprived of basic care and needs such as hydration and nutrition. In some cases there was a perception among caregivers that patients were being unnecessarily sedated with opioids and sedatives prescribed routinely for dying patients. While it seemed that the medical staff felt more comfortable in delivering effective symptom control with the LCP, this did not necessarily translate into good care as perceived by caregivers.

Several reports have been published by various institutions about their own experience with regards to use of the LCP or a coordinated pathway for end-of-life care. A retrospective case notes audit by the Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) found that communication with caregivers of dying patients on the LCP were better with less uncertainty within caregivers. ⁵ Philips et al. found that the doses of opioids and sedatives given to patients on the LCP in a large district general hospital in the United Kingdom were safe and not unduly increased. ⁶ A survey of health care providers working in a U.K. hospital setting found that the majority of staff were able to recognize when to start LCP and decide on the appropriate monitoring and treatment. ⁷ However, a cluster randomized trial done by Costantini et al. showed no improved benefit in overall quality of care when LCP was in use. ⁸

The Care of the Dying clinical coordinated Pathway (CDP) was adapted largely unchanged from the LCP version 11, with only changes in layout and omission of the section on communication with the primary health care team. It was started in 2007 in a 1597-bedded tertiary hospital in Singapore with the aim of providing better symptom control and overall care for dying patients. The CDP was initially implemented in the oncology ward, where a subsequent audit found improved symptom control, more frequent prescription of preemptive breakthrough medications, and decrease in frequency of inappropriate monitoring with the use of such a protocol-based pathway. ⁹ The CDP was subsequently extended to the renal wards.

In view of the controversies surrounding LCP, this audit was performed to assess if similar problems found in the Neuberger review had occurred and if there is still a role for the CDP in our care setting.

Methods

A retrospective audit was conducted in early 2014 looking at all patients started on the CDP in the oncology and renal wards during a two-year period from July 2011 to June 2013. The patients were identified from the hospital's Quality Management Department, which monitors the use of pathways in the hospital, and from records of CDP use in the wards, which is monitored by the Department of Palliative Medicine. These case records were reviewed, together with online medical records of medications prescribed and vital signs monitoring.

A data collection form was used to assess the documentation on various aspects of care while the patient was on the CDP. This included:

1. Decision for initiating the CDP, including the seniority of the physician, the time of initiation, and fulfilment of the inclusion criteria. The inclusion criteria were similarly defined in the LCP, with at least two of the following patient clinical conditions present: being bedbound, comatose state, only able to take sips of fluids and no longer able to take tablets, AND with the multidisciplinary team agreeing that the patient is dying with little chance of recovery.

Data collection was performed by two palliative care physicians from the Department of Palliative Medicine, National Cancer Centre Singapore. The information obtained from the data collection form was transferred and analyzed using Microsoft Excel. Institutional review board approval was obtained prior to initiation of the study.

Results

There were a total of 740 deaths in the oncology ward, with 90 (12.2%) started on the CDP (see Fig. 1). In the renal wards, a total of 129 patients died during the period of study, with 29 (22.5%) patients started on the CDP. The medical records of 82 oncology patients and all 29 renal patients were successfully traced and assessed. Seventy-eight (95%) oncology patients and 25 (86%) renal patients passed away while on the CDP.

OPEN IN VIEWER

FIG. 1.

Flowchart of obtaining patients' records.

Discussion

Overall, the audit did not seem to demonstrate any significant compromise in medication safety, monitoring of the dying patient, and provision of nutrition and hydration.

With regards to communication, our audit noted that a high proportion of caregivers were informed of the poor prognosis of their loved one, including the plan for comfort care. However, communication with patients about their extent of care and their prognosis was still infrequent. One likely reason was that more than half of patients were already confused or unconscious by the time discussions on end-of-life care arose. This was also observed by Chong et al., where the authors noted that patient involvement in decision making decreased as their illness progressed. ¹⁰ Cultural practices also play a part. In Singapore, where a family-centered model for decision making is still common, it is more likely that end-of-life discussions are held with the family, rather than the patient himself.^11,12 In addition, it has been recognized that end-of-life discussions with patients are often deemed difficult and uncomfortable for health care workers.^13,14

Our results showed little documentation about discussion with family members regarding the use of the CDP before its initiation. In retrospect, this may not have been adequately stressed during the implementation of the pathway. There were also no health care pamphlets available in our local setting for explanation regarding the pathway, unlike in the U.K. LCP setting. Thus, improved communication and documentation about such discussions should be encouraged in future, together with appropriate education aids and reminders during implementation.

Although there was a lack of communication with the caregivers prior to the use of opioids or sedatives, all patients were subsequently duly reviewed after these medications were started to prevent possible oversedation or side effects from the medications started. This would also reassure caregivers that while their loved ones were prescribed opioids and sedatives, there was active monitoring for excessive sedation with the intention to treat symptoms rather than hasten death.

In our audit, a high proportion of patients continued to have artificial hydration while on the CDP. However, in patients whose intravenous drips were stopped, there was no documentation that their caregivers were informed. Although artificial hydration at the end of life has not been shown to improve symptoms, quality of life, or survival, the decision for institution of artificial hydration is a sensitive decision to caregivers. ¹⁵ In the Asian culture where oral feeding and maintaining nutrition is an important act of caregiving, the fear of loved ones being dehydrated or ‘starved to death’ needs to be allayed and documented.

With regards to decision making, our audit found that the majority of CDPs were appropriately initiated by trained senior staff during office hours, with the inclusion criteria met.

In our audit, the utilization rate of the CDP was only 12% and 22% for the oncology and renal patients, respectively. This is relatively low compared to another U.K. audit done by the Royal College of Physicians, which found that 48% of the sampled patients were supported by a framework of care including advanced care planning, an electronic palliative care coordination system, or a “rapid discharge home to die” bundle. Notably, hospitals and other health care facilities in Singapore also do not receive any financial reimbursement for patients being on the CDP. This is in contrast to the United Kingdom where LCP use was seen as a good clinical practice and its use was encouraged with financial incentives, although this was not universal.

This audit was limited in several aspects. The retrospective nature of this review resulted in difficulty distilling between actual discussions not taking place versus poor documentation by the team. Seeking the viewpoints of caregivers as well as health care workers involved would have also given us more insight on the perceived benefits and concerns in the use of the CDP.

In response to the Neuberger review, the Leadership Alliance for the Care of Dying People has stated that the approach to end-of-life care should focus on five priority areas rather than the delivery of protocols or pathways. ¹⁷ Physicians are encouraged to focus on these five priority areas:

1. The recognition of the dying patient and decisions made in accordance with the patient's needs and wishes, which should be reviewed regularly.

Noticeably, these five areas appear similar to the goals of the LCP. To date, the benefits and harms of having a pathway in end-of-life care continue to be debated. Proponents of such a pathway suggest that the inappropriate execution of the pathway should not warrant the absolute withdrawal of such a pathway in the future.^18,19 A care pathway for the dying may still have the potential to close the gap between differing levels of care between the hospice and hospital.^8,20 Thus, some physicians suggest that future plans should be made to optimize the use of such a pathway, rather than replace it with another set of guidelines, which has not been proven effective either. ¹⁹

From our audit we found that despite adopting a coordinated pathway for dying patients, documentation of important end-of-life conversations remain poor. While this may not reflect poor communication from clinicians affecting caregivers' perception of end-of-life care, the importance of systematic discussion and documentation cannot be overemphasized. While an increased focus on education and research can support and allow optimal adoption and continual execution of end-of-life care based on these five priority areas, there needs to be a better way of encouraging documentation of important end-of-life care decisions and communication. Our study, though in a non-U.K. setting, highlights similar issues surrounding the LCP as seen in the wider palliative care community.^21–25

Conclusion

There was no documented compromise in medication safety, clinical monitoring, and provision of nutrition and hydration for patients on the CDP. However, communications with patients and family members about initiation of opioids, use of opioids or sedatives, and withdrawal of artificial hydration were poorly recorded. Development of an alternative care tool with emphasis on guidelines encouraging systematic discussion and documentation of individualized end-of-life care plans should be considered.